MDS Alert
Clean Up Your Care Plan Problem List
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Consider using the SOAP approach.
Looking for a way to stay on top of each resident's problem list? One option is to use a problem-oriented record where you number the problems and document using a SOAP format to address each problem.
SOAP stands for Subjective data where you record what the patient or family member communicates, Objective data (what you see, touch, hear, smell, measure, etc.), Assessment or analysis of the data, and the Plan to address the problem. "As a problem resolves, you cross it off and add new ones as they evolve," says Carol Job, RN, a consultant with Myers & Stauffer in Topeka, KS. "By using that approach, everyone can quickly see what a resident's active problems are, what's resolved, what's new," says Job.
Another perk: "The SOAP method forces you to do some critical thinking [because] you have to analyze the information gathered," observes Joy Morrow, RN, PhD, a consultant with.Hansen, Hunter & Co., Beaverton, OR.
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